Florida Network of Youth and Family Services Quality Improvement Program Report

Transcription

1 Florida Network of Youth and Family Services Quality Improvement Program Report Review of Orange County on 10/22/2013 page 1 / 19

2 CINS/FINS Rating Profile Standard 1: Management Accountability 1.01 Background Screening Satisfactory 1.02 Provision of an Abuse Free Environment Satisfactory 1.03 Incident Reporting Satisfactory 1.04 Training Requirements Satisfactory 1.05 Analyzing and Reporting Information Satisfactory Percent of indicators rated Satisfactory:100.00% Percent of indicators rated Limited:0.00% Percent of indicators rated Failed:0.00% Standard 3: Shelter Care 3.01 Shelter Environment Satisfactory 3.02 Program Orientation Satisfactory 3.03 Youth Room Assignment Satisfactory 3.04 Log Books Satisfactory 3.05 Behavior Management Strategies Satisfactory 3.06 Staffing and Youth Supervision Satisfactory 3.07 Special Populations Satisfactory Percent of indicators rated Satisfactory:100.00% Percent of indicators rated Limited:0.00% Percent of indicators rated Failed:0.00% Standard 2: Intervention and Case Management 2.01 Screening and Intake Satisfactory 2.02 Psychosocial Assessment Satisfactory 2.03 Case/Service Plan Satisfactory 2.04 Case Management and Service Delivery Satisfactory 2.05 Counseling Services Satisfactory 2.06 Adjudication/Petitiion Process Satisfactory 2.07 Youth Records Satisfactory Percent of indicators rated Satisfactory:100.00% Percent of indicators rated Limited:0.00% Percent of indicators rated Failed:0.00% Standard 4: Mental Health/Health Services 4.01 Healthcare Admission Screening Satisfactory 4.02 Suicide Prevention Satisfactory 4.03 Medications Satisfactory 4.04 Medical/Mental Health Alert Process Satisfactory 4.05 Episodic/Emergency Care Satisfactory Percent of indicators rated Satisfactory:0.00% Percent of indicators rated Limited:0.00% Percent of indicators rated Failed:0.00% Overall Rating Summary Percent of indicators rated Satisfactory:100.00% Percent of indicators rated Limited:0.00% Percent of indicators rated Failed:0.00% Rating Definitions Ratings were assigned to each indicator by the review team using the following definitions: Satisfactory Compliance Limited Compliance Failed Compliance No exceptions to the requirements of the indicator; limited, unintentional, and/or non-systemic exceptions that do not result in reduced or substandard service delivery; or exceptions with corrective action already applied and demonstrated. Exceptions to the requirements of the indicator that result in the interruption of service delivery, and typically require oversight by management to address the issues systemically. The absence of a component(s) essential to the requirements of the indicator that typically requires immediate follow-up and response to remediate the issue and ensure service delivery. Review Team Members Ashley Davies, Lead Reviewer, Consultant, Forefront LLC Stephen Reid, Contract Manager, Florida Department of Juvenile Justice Eric Fadely, Juvenile Assessment Center Program Coordinator, Crosswinds Youth Services, Inc. page 2 / 19

3 Joseph Hernandez, Clinical Program Supervisor, WaveC.R.E.S.T. Shelter for Teens page 3 / 19

4 Persons Interviewed Program Director DJJ Monitor DHA or designee DMHA or designee 3 Case Managers 0 Maintenance Personnel 2 Clinical Staff 2 Program Supervisors 0 Food Service Personnel 0 Other 0 Health Care Staff Documents Reviewed Accreditation Reports Fire Prevention Plan Vehicle Inspection Reports Affidavit of Good Moral Character Grievance Process/Records Visitation Logs CCC Reports Key Control Log Youth Handbook Confinement Reports Logbooks 4 Health Records Continuity of Operation Plan Medical and Mental Health Alerts 4 MH/SA Records Contract Monitoring Reports PAR Reports 6 Personnel Records Contract Scope of Services Precautionary Observation Logs 6 Training Records/CORE Egress Plans Program Schedules 4 Youth Records (Closed) Escape Notification/Logs Sick Call Logs 4 Youth Records (Open) Exposure Control Plan Supplemental Contracts 4 Other Fire Drill Log Table of Organization Fire Inspection Report Telephone Logs Surveys 5 Youth 6 Direct Care Staff 0 Other Observations During Review Admissions Posting of Abuse Hotline Staff Supervision of Youth Confinement Program Activities Tool Inventory and Storage Facility and Grounds Recreation Toxic Item Inventory and Storage First Aid Kit(s) Searches Transition/Exit Conferences Group Security Video Tapes Treatment Team Meetings Meals Sick Call Use of Mechanical Restraints Medical Clinic Social Skill Modeling by Staff Youth Movement and Counts Medication Administration Staff Interactions with Youth Comments Items not marked were either not applicable or not available for review. page 4 / 19

5 Strengths and Innovative Approaches More collaborative efforts are being made with the youth shelter and other outside agencies to provide groups and activities to enhance the services being offered to the youth. Life skills groups are conducted at Florida Hospital called Mission -Fit-Possible which focus on health and wellness. The youth gave positive feedback regarding the activities, as well as, the wealth of information that was provided by the trainer. The Health Department conducts sexual health groups monthly aimed at prevention/intervention. Planned Parenthood leads a monthly group session Teens in Charge. A detective from the Orlando Police Department, Special Victims Unit/Missing Children, conducts quarterly group sessions with the youth that address runaway and missing children issues. Trauma Informed Training provided by SAMHSA was well received by the staff and trauma informed care practices are being utilized at the shelter. As a result, counselor s offices have been painted in a Sage color to evoke a soothing, more therapeutic environment. Each counselor has personalized their office space by adding their decorative touches that include a water fountain to produce a more soothing atmosphere during counseling sessions. Several rocker/glider chairs were placed in the multipurpose room and counselor s offices to evoke a soothing and more therapeutic environment for the children. The entire staff at the youth shelter completed the twenty-hour Trauma Informed Care (TIC) training. The training highlighted best practices and provided the staff with valuable information on how to appropriately engage the youth. The shelter s sensory cart was completely replenished with additional calming items for the youth. Items include, but are not limited to, a massage chair pad, stuffed animals, squeeze toys, bubble wrap, and sour candies. Upon admission to the shelter, each child receives a welcome bag with items such as a t-shirt, journal note book, pencil, and bubble wrap for popping. The shelter is in the process of revising their behavior management system to embrace a more trauma informed care approach with several posters being displayed to address staff/youth interactions. The Acting Program Manager recently joined the Human Trafficking Task Force and will be attending the monthly stakeholders meetings. These meetings provide opportunities to collaborate with law enforcement agencies and other human services providers who share ideas and strategies to better serve human trafficking victims. The Youth Shelter recently completed the division internal program review and received an outstanding score of 100% in compliance. Several youth from the shelter participated in Stop the Violence Youth Summit in June that addressed human trafficking, and social media. Another outstanding activity that the youth attended was the Game of Life provided by the University of Central Florida that encourages self-sufficiency and money management using real life scenarios. The youth went on a tour of Florida Hospital South that included the helicopter launch pad for trauma care arrival. An intercom system was installed at the main entrance of the youth shelter. This allows staff to control who enters the building by viewing and speaking with visitors before they are let in. Parenting classes are being offered to parents/caregivers that cover a variety of topics such as positive discipline techniques, behavioral issues, and coping skills. page 5 / 19

6 Overview Standard 1: Management Accountability Narrative Orange County Youth and Family Services Division (OCYFS), through the Orange County Board of County Commissioners, contracts with the Florida Network of Youth and Family Services, Inc. to provide shelter and non-residential services for youth and their families in Orange County. The program located at 1800 East Michigan Street, Orlando, Florida is under the leadership of the Orange County Government. Program Managers oversee the residential and non-residential components of the program, including the volunteer and outreach initiatives. The program managers are responsible for supervising and conducting staff meetings with their respective staff members and conducting program-specific outreach. The shelter is licensed for twenty beds; at the time of the quality improvement review there were a total of seven youth who were CINS/FINS. The shelter is comprised of a building that has two separate hallways on opposite sides of the building, to house female youth on one hallway, and male youth on the other. Each hallway can house up to twelve youth. The hallways are separated by a dayroom, a kitchen and master control. When not in school, the youth spend a majority of their free time in the dayroom either engaged in group activities, playing video games, watching television or completing homework assignments on the computers. There is onsite school that the youth attend from 8:30 a.m. 2 p.m. as well as a cafeteria on-site in which the youth eat their meals. The program maintains an individual training file for each employee, with training provided through the Florida Network, computer-based training's and by Orange County staff. Upon attending outside trainings, staff members are responsible for submitting the documentation for recording in their training file. Annual training is tracked according to the employee s date of hire. The entire staff at the youth shelter has completed the twenty-hour Trauma Informed Care (TIC) training. This training highlighted best practices and provided the staff with valuable information in how to appropriately engage the youth we currently serve. At the time of the quality improvement review there were no vacancies in the youth shelter or the non-residential component of the program Background Screening The agency has policies and procedures that address background screening in accordance with Florida Statues Chapter for all employees, interns, and volunteers. The agency also complies with the Orange County Government's internal policies and procedures. The agency conducts preliminary background screenings and driver's license checks for all of their potential employees, interns, and volunteers prior to their official start date. Favorable findings are required prior to an offer of employment, volunteer, or internship. In addition to the DJJ Background Screening, the agency also conducts annual driver s license checks, annual local county background screenings, and annual Florida Sex Offender checks on all employees. A drug screening and a polygraph test are completed at hire and random drug screenings are also conducted thereafter. There were two newly hired staff and one newly hired intern since the last quality improvement review. Both staff and the intern all received eligible screening results prior to their start dates. There were no staff eligible for five year re-screenings since the last quality improvement review. The Annual Affidavit of Compliance was signed by Phil Whitby on January 14, 2013 for ten staff for the non-residential component of the program. An additional Annual Affidavit of Compliance was signed by Tracy Salem on January 14, 2013 for twenty-three staff for the residential component of the program. Both of the affidavits were submitted to the DJJ Background Screening Unit prior to the January 31st deadline Provision of an Abuse Free Environment page 6 / 19

7 The agency has policies and procedures that address all of the requirements. All new staff sign an Acknowledgement of Receipt for the agency s Code of Conduct and this is placed in their personnel file. New employees receive child abuse and incident reporting training during orientation training upon hire and then annually thereafter. This was documented in all training files reviewed. All staff sign another acknowledgement regarding their individual requirement to report child abuse that also becomes a part of their personnel file. Postings of the abuse hotline number, combined with the telephone numbers of Department of Children and Families, Orange County Sheriff s Office and Orlando Police Department are located in key areas of the facility. Rights and responsibilities are also posted in dormitory hallways. Two grievances were filed in last six months. Both grievances were resolved on the supervisory level. Four of the five youth surveyed reported that they were aware of the abuse hotline and two of those youth knew how to find the number. Four of the five youth reported that staff were respectful when speaking with them or other youth and one youth reported they were not. All five youth reported they have never heard staff use inappropriate language and they feel safe in the shelter. All six staff surveyed reported youth are able to self report abuse to the abuse hotline and they have never heard another staff member deny a youth access. All six staff also reported they have never heard another staff member using profanity, threats, intimidation, ect., when speaking to the youth Incident Reporting The Agency has policies and procedures in compliance with DJJ incident reporting. A separate facility incident report binder has current incident reports and previous incident reports dating back several years. Onsite documentation of internal reports was made available and copies were taken. All documentation reviewed was legible and clearly described the incidents with the time frames listed. The supervisor/program manager reviewed and signed the documents with recommendations and/or other actions. Eleven incident reports were reviewed from the last six months. Several incidents recorded were followed up with an interview with the Program Manager due to the sensitive nature of personnel action taken. All incidents were reported within the allotted time frame and all were in compliance and appropriate documentation and follow up action was taken. Additionally, the Agency tracks all incidents in quarterly risk management reports that are reviewed by management Training Requirements The Agency has policies and procedures to ensure staff receive the required minimum training annually. The Training policy was revised on 7/12/13. The "Staff Development Training Plan Goals and Schedule " policy contains seven goals and objectives and training requirements for all staff. This annual training is reviewed and signed by both the employee and their supervisor. The annual training calendar is from July 2013 to June 2014 and lists dates, times, facilitators, duration of training's and location of training's. Three first year training files and three annual training files were reviewed. Three files were residential employees including one supervisor and three files were non-residential staff. All training files were updated for the current training year, beginning in July 2013, with their individual training requirements for the year. Four staff were employed over a year and are completing their annual training requirements. These four are on target to complete their training requirements or have already completed their training. Two staff were hired in 2013 and are completing their first year of training. These two new hires both had well over the required eighty hours of training with one staff member completing in excess of 300 hours in seven months. Thirteen staff members received twenty-four hours of Trauma Informed Care training in October page 7 / 19

8 1.05 Analyzing and Reporting Information The agency has a Performance and Quality Improvement Plan in place that is used for analyzing data and trends on a quarterly basis. This plan includes compliance issues, grievances, incidents/accidents, use of behavioral interventions, safety and security, medication records, case record reviews, grievances, customer satisfaction, and outcome data. Procedures for the review of Netmis reports are also included. Consumer satisfaction surveys are completed for both employees and clients. Data from these questionnaires are analyzed for internal quality improvement purposes. Youth feedback is solicited on a regular basis through client surveys, grievance process, and suggestions. Two minor medication errors resulted in direct care staff being trained directly by a nurse in an effort to enhance the training and reduce errors. Two grievances were filed in last six months. Both grievances were resolved on the supervisory level. Monthly management and staff meetings are held to discuss the findings of the various data analysis activities. Netmis data and program benchmarks are reviewed and data quality checks are performed. The 2013 Orange County Family Services Department Resource Guide has been sent electronically to all staff. This forty-eight page resource guide is being used for referrals and information to parents and youth. Management attends Children and Family Services Board meetings, Youth & Families Division Senior & Program Manager meetings, Community Advisory Board, supervisory and staff meetings, Circuit 9 Juvenile Justice Board and Orange County Juvenile Justice Council. Information is then used to disseminate data and identify trends and needs. page 8 / 19

9 Overview Standard 2: Intervention and Case Management The Family Counseling Program provides non-residential services for youth and their families in Orange County. The program s main office is located at 507 East Michigan Street, Orlando, Florida. The non-residential component consists of a program manager, a counseling services supervisor, an administrative specialist, six senior children s services counselors, a court supervision children s services counselor, and an intake and screening counselor. The program s intake and screening counselor initially handles calls from the public, as well as calls through the crisis intervention and screening unit (CISU). The screening counselor will either refer the youth and family to one of the program s counselors, or will make a referral for the family to another appropriate community agency, according to the youth's zip code. Case management and substance abuse prevention education are also offered. Referral and aftercare services begin when the youth are admitted for services. OCYFS coordinates the Case Staffing Committee, a statutorily-mandated committee that develops a treatment plan for habitual truancy, lockout, ungovernable, and runaway youth when all other services have been exhausted or upon request from the parents/guardians. The Case Staffing Committee can also recommend the filing of a CINS Petition with the court Screening and Intake Eight youth files were reviewed: four residential files and four non-residential files, for screening and intake requirements. All of the residential and non-residential files were screened for eligibility within seven calendar days of referral. It is listed as a program standard in the file checklist form located in all non-residential files that contact will be made with families by a CINS/FINS Non Residential Counselor within forty-eight hours of receiving a screening. This was evidenced by the client contact notes located in the four non-residential files reviewed. Youth and parents/guardians were all informed of their rights and responsibilities, grievance procedures, and available service options in writing. This was evidenced, in the residential files, by consent forms and the Client Orientation Checklist. In the non-residential files, this was evidenced by consent forms and the Parent Notification of Program Expectations Form. There were NETMIS numbers missing from documentation (screening form, youth program log and NETMIS program log) in all four residential files reviewed. It was explained by the shelter Program Manager that NETMIS numbers are added into residential files at discharge. This was verified by the review of additional closed residential files Psychosocial Assessment All four of the residential files reviewed had psychosocial assessments initiated within seventy-two hours of admission. Addendum pages were included in residential files with psychosocial assessments that had been completed within six months of shelter intake. All four of the nonresidential files reviewed had psychosocial assessments completed within two to three face to face contacts. It is listed as a program standard in the file checklist form located in all non-residential files reviewed that psychosocial assessments will be completed within fourteen days of page 9 / 19

10 intake. This was evidenced by the psychosocial completion dates located in the four non-residential files reviewed. All eight psychosocial assessments reviewed were completed by a Master's level staff and reviewed/signed by a licensed supervisor. There were no youth identified with an elevated risk of suicide, as a result of the psychosocial assessment, in any of the files reviewed Case/Service Plan All residential and non-residential files reviewed included service plans that were developed within seven working days of psychosocial assessment. The residential and non-residential service plans reviewed included individualized goals that documented all required elements. This included dates of initiation in all the residential and non-residential plans reviewed. All signatures were present in the four non-residential files reviewed. If there were any signatures that were not present in the residential files, it was documented in the progress notes as to why these were not present. All of the residential files reviewed had service plans that were reviewed for progress and amended, if needed, within required time frames. The review for progress and revisions of service plans by the counselor and parent, every thirty days for the first three months and every six months thereafter, were present in the four non-residential files reviewed. The file checklist form located in non-residential files is an excellent tracking tool to ensure that service plans are being revised and amended within required time frames Case Management and Service Delivery All four residential and four non-residential files reviewed included referral needs, coordination of referrals made, coordination of service plan implementations and evidence of family support. This was documented in the service plans and progress notes located in all files. The referral tracking tool located in the non-residential files is an excellent way to track what agencies a youth has been referred to and the progress towards successfully completing each referral made. This tool also identifies possible barriers to service. Three of the four residential files reviewed were court ordered. All three files had court orders located within the file. A 180 day follow up was completed in all residential and nonresidential files reviewed that had been closed for six months. page 10 / 19

11 2.05 Counseling Services All four residential and four non-residential files reviewed received counseling services in accordance with service plans located in the files. This was evidenced in the progress notes located in the residential files. These progress notes document that individual/family counseling is provided to all youth and their families while shelter services are provided. The progress notes located in the non-residential files documented counseling services were provided for youth in the home, school and community. This included coordination of care between multiple agencies. There was evidence in multiple places in the residential files that group counseling is offered to youth at least five days a week. There was documentation that the youth in residential care and non-residential care have their presenting problems addressed in psychosocial assessments and service plans. Progress notes maintained in all files reviewed documented progress made by youth in residential and non-residential care. Signatures from licensed supervisors in residential and non-residential files documented that clinical reviews of files and ongoing evaluations of staff performance are being performed regularly Adjudication/Petitiion Process Three of the four non-residential files reviewed had cases where it was necessary for the case staffing committee to become involved. All three of the files documented whom the case staffing was initiated by. The parent/guardian and case staffing committee was given written notice no less than five working days prior to the case staffing in all of the files reviewed. This was documented in the contact notes and written correspondence section located in section five of the non-residential files. All three files documented the case staffing committee members included representatives of the local school district, DJJ and CINS/FINS providers. Additional case staffing committee members identified were mental health and DCF representatives. There were revisions made to the case plans after the completion of case staffing's. All three files documented a written report was sent to the parents/guardians within seven days of the case staffing. This documentation was located in the contact notes and written correspondence section of the files. There was also evidence of coordination of care with the circuit court for judicial intervention when it became necessary. This was documented in the contact notes and the review summary completed by the assigned counselor/case manager prior to the completion a case staffing Youth Records All residential and non-residential youth records are marked "confidential" and kept in a secure room or locked file cabinet that is also marked confidential, which is accessible to only program staff. The residential files are housed in a locked filing cabinet marked "confidential", that is located in the staff office. This area is accessible only to program staff. All closed residential files are housed in a locked room that is accessible only to program staff. All open and closed non-residential files are located at 500 E. Michigan Street, Orlando, FL All files are located in a secure room, in locked file cabinets, that is only accessible to program staff. page 11 / 19

12 Overview Standard 3: Shelter Care OCYFS Youth Shelter is located in Orange County. The facility is in operation twenty-four hours per day, seven days per week, every day of the year and is licensed by the Department of Children and families for twenty beds. Youth admitted in the shelter program are provided with an orientation of the shelter, which includes a review of the youth handbook with the staff, and a time to ask questions and take a tour of the shelter. The shelter staff includes a program manager, an administrative specialist, a senior youth care supervisor, a counseling services supervisor, three senior counselors, two children services counselors, seven case workers, four family teacher assistants, and two youth resident coordinators. The family youth resident coordinators and teacher assistants are responsible for completing all applicable admission paperwork, orientating youth to the shelter, and providing necessary supervision. The shelter s direct care staff are trained to provide the following services for the youth: medication administration; health, mental health and substance abuse screenings, first aid, cardio pulmonary resuscitation (CPR) and referrals. The supervisory and counseling staff receive referrals and monitor the provision of services. The medication and first aid supplies are stored in the staff office adjacent to the multi-purpose room. The counseling staff have offices in the hallway adjacent to the girls dorm, and in the front office hallway. Residential services, including individual, family, and group services, are provided. Case management and substance abuse prevention education are also offered. The shelter has a color-coded medical and mental health alert system in place. The program also has an effective grievance process, in which both of the grievances were responded to within twenty-four hours of being submitted to management. At the time of the quality improvement review, the shelter was providing services to seven CINS/FINS youth. The shelter is not designated by the Florida Network to provide staff secure services and is not licensed under Chapter Shelter Envonment The shelter has had one health inspection completed since the last review. The inspection was completed on December 12, 2012 and did not note any violations. A fire safety inspection was completed on October 9, 2013 and also noted no violations. A tour of the shelter revealed all furnishings were in good repair and well maintained. The shelter has a pest control company and was free of insect infestation. The grounds were well landscaped and maintained. Bathrooms and showers, in both the boys and girls halls, were extremely clean and functional. There was no graffiti observed on any wall, door, or window in the shelter. Each youth was given their own individual bed with a clean mattress, pillow, sheets, and quilt. All the lighting throughout the shelter was functional and appeared adequate for the tasks performed there. All youth's personal belongings were maintained in a locked cabinet in the staff office. The shelter adheres to a daily schedule that ensures youth are engaged in meaningful, structured activities seven days a week during awake hours. The daily schedule designates times for meals, education, groups, recreation, hygiene, chores, and snack time. The schedule allows for very minimal idle time. Documentation reviewed in logbooks revealed the daily schedule was followed. Youth are allowed one hour of physical activity per day. If the weather is too hot for outdoor activities the shelter has alternative activities the youth can do indoors. Youth are provided an opportunity to participate in faith based activities every Sunday. The youth's parent are given the option of picking the youth up from the shelter and taking them to their church. The youth who remain in the shelter on Sunday are able to turn on any faith based service on the the television to watch. Daily programming allows youth time to complete homework and also allows the youth quiet time to read. The shelter has a library of age appropriate books approved for the youth to read. The school the youth attend on-site also has a library of age appropriate books the youth can check out and read. All youth receive a copy of the daily schedule during orientation and the schedule is also posted in the male and female hallway and the day room for the youth and staff to view throughout the day Program Orientation Within twenty-four hours of admission to the shelter the Senior Children Services Counselor or person in charge ensures that the caseworkers orient youth to shelter procedures using the Client Orientation Checklist. During orientation youth are given a Welcome to the Shelter bag containing the Youth Shelter Handbook that includes information about the shelter including, the youth's rights, program rules, the behavior management system, and the schedule. Hygiene products are also dispersed at this time. The youth are introduced to key staff and their roles, page 12 / 19

13 given a tour of the facility, given an overview of policies, and given linens for their rooms. Five youth files were reviewed, two closed and three opened, for documentation of program orientation. All five files documented an orientation was completed with the youth within twenty-four of admission to the shelter. The Youth Orientation Checklist was completed in all five files and included orientation topics and dates of presentation, as well as, signatures of the youth and staff involved. The orientation checklist documented all required topics were covered. All five files also documented the youth received a copy of the Youth Handbook during the orientation process. Two of the five files reviewed did not document a room assignment in the youth's file; however, a room assignment was documented on the alert board in the staff office. The remaining three files documented a room assignment in the file Youth Room Assignment Upon admission to the shelter, youth are interviewed by staff to determine the most appropriate sleeping room assignment. All determinations of youth room assignment are documented in the logbook and/or the youth's file. An alert is immediately entered into the shelter's alert system if the youth is admitted with special needs or risks. The shelter uses the CIN/FINS Intake Assessment Form to classify youth for room assignment. The form documents all required information. All five youth files reviewed documented this form was completed at the time of the youth's admission to the shelter. Three of the five files documented the youth were appropriately assigned to a room. The remaining two files did not document any room assignment in the youth's file; however, a room assignment was documented on the alert board in the staff office for both youth. All alerts were appropriately entered into the shelter's alert system Log Books Shelter log books were reviewed for the previous six months. The shelter uses color coded highlighting system to highlight any entries that could impact the security or safety of the youth or program. The log books reviewed revealed staff were using the highlighting system appropriately and all entries were highlighted in their respective color if required. Entries were brief and were generally legible. All entries were written in ink and included the date and time of the incident, activity or event, names of youth and staff involved, and the signature of the person making the entry. All errors reviewed in the log books were struck through with a single line and initialed by the staff member. Weekly reviews of the log book by the Shelter Director were consistently documented. There was also consistent documentation from the oncoming supervisor reviewing the log book for the previous two shifts. There was documentation in the log books of all staff on duty for the shift signing in; however, there was not consistent documentation of the staff reviewing the log book for the previous two shifts. page 13 / 19

14 The shelter has a four level behavior management system in place that is based on a nautical theme. The four are: Level 0 = Ensign, Level 1 = Lieutenant, Level 2 = Commander, and Level 3 = Captain. The system is designed for short term residential stays. Youth purchase levels based on the number of points they earn through out the day. Points are earned for successfully managing required behaviors by making good decisions, self management, and social and life skill management. Points are deducted for unacceptable behaviors. Youth will be issued the maximum number of points allowed for each required behavior category unless they are issued a fine for unacceptable behavior. If a youth is issued a fine, points will be deducted from the maximum to coincide with the infraction. Fines are issued in 10, 20, or 30 point increments.any of the four levels can be purchased, the more points a youth earns, the higher the level they can purchase, which directly coincides with more rewards and privileges for the youth. Youth can earn a maximum of 500 points each day and Level 0 can be purchased for 349 points, Level 1 can be purchased for 350 points, Level 2 can be purchased for 400, and Level 3 can be purchased for 450 points. The behavior management system is based on positive reinforcement and logical consequences. The system prohibits the use of group discipline and also prohibits youth imposing disciplinary consequences/sanctions over other youth. The shelter also prohibits the use of adverse stimuli, with holding food, punitive work assignments, cancellation of visits, or the use of demeaning activities or words.the system also requires that when a major program rule is violated, the sanction must be reviewed and signed by a supervisor. The system uses a wide variety of rewards including: The Way-To-Go Store, extra snacks, community outings, extended weekend bedtimes, pizza parties, and ice cream socials. Point cards reviewed in youth files and documentation reviewed in logbooks revealed staff are utilizing the behavior management system consistently and appropriately. Points were appropriately documented on point cards and infractions were documented on the Behavior Management System Infraction Slip. All staff are trained on the behavior management system during their orientation training completed upon hire. Supervisors are also trained to monitor the use of behavioral interventions by their staff Staffing and Youth Supervision The shelter has weekly staff schedules in place to ensure that minimum staffing ratios are maintained. Documentation reviewed in logbooks and on staff schedules revealed that a one staff to six youth ratio was maintained at all times during the awake hours and a one staff to twelve youth ratio was maintained at all times during the sleeping hours. There were many instances where the shelter exceed the minimum staff ratio requirements. Documentation reviewed also revealed there was always at least one female and one male staff on duty at all times. The staff schedule also assigns one person on the each shift to sight and sound if needed, medication distribution, close observation if needed, and assigns one staff to the office to ensure all required documentation during the shift is completed. Each staff is required to sign the work schedule each week to confirm they have read the schedule and are aware of the days and hours they are required to work. The weekly schedule also assigns an "on-call" person each day and in the event someone does not show up for their shift, the outgoing staff is not allowed to leave until he or she is relieved of duty or have permission to leave from a supervisor once there is adequate coverage. Documentation reviewed revealed that fifteen minute room checks were maintained at all times during the sleeping hours. Resident Accountability Checklists were reviewed for random days during the last six months and confirmed that the fifteen minute checks were documented and initialed for each day reviewed. The male room checks were always completed by a male staff and the female room checks were always completed by a female staff Special Populations page 14 / 19

15 Th shelter has a policy in place and floating beds available to serve domestic violence youth that are referred for respite placement. All four youth files reviewed documented a pending domestic violence charge and had been screened by the JAC. Three of the four files did not exceed a length of stay of fourteen days. The fourth youth was in shelter for 19 days with no documentation of a transition to CINS/FINS respite placement. All four case plans reviewed reflected goals of aggression management, family coping skills, and other interventions designed to reduce propensity for violence in the home. All services provided to these youth were consistent with all other CINS/FINS program requirements. page 15 / 19

16 Overview Standard 4: Mental Health/Health Services OCYFS has specific procedures related to the admission, interviewing and room assignment of youth to ensure the safety and appropriate supervision of youth admitted in the program. Upon admission, program staff will interview youth. An initial assessment occurs to determine the most appropriate room assignment given the youth s needs and issues, the current population at the facility, physical space available and staff's assessment of the youth's ability to function effectively within program rules and expectations. Staff conducting the initial interview and assessment considers the youth's physical characteristics, maturity level, history including gang or criminal involvement, potential for aggression, and apparent emotional or mental health issues. Based on this information, the youth is assigned a room which can change after further assessment. Room assignment is documented on the CINS/FINS Intake Assessment page 2. Staff on duty at the time of admission immediately identifies youth who are admitted with special needs and risks, such as risk of suicide, mental health, substance abuse, physical health, or security risk factors, etc. The shelter manager, licensed clinician, and/or youth resident coordinator is notified immediately if risks and/alerts are present and recommendations regarding placement and supervision are provided to the direct care staff. This information is documented in the daily log, on the alert board, and in the youth files using a color coding system. Youth admitted to the shelter with prescribed or over the counter medication will surrender those medication to staff during admission. Medications are stored in a double locked cabinet, and topical and/or injectable medications are stored separately from oral medication. Refrigeration is available for medication requiring cool storage. The program has a list of staff who are authorized to distribute medication ensures that an approved staff is scheduled on each shift. Medication records are maintained for each youth and stored in a MDR Binder Healthcare Admission Screening Four files were reviewed for completion of Healthcare Admission Screening. Two were open residental files, one was a closed residential file, and one was an open non-residential file. All four files documented a physical health screening was completed on each youth at admission that included all requirements. The shelter has a process in place for youth admitted with chronic medical conditions. One file reviewed documented no chronic conditions on the physical health screening at admission; however, during completion of the psychosocial assessment it was noted that the youth had asthma. There was no documentation there was any communication with the youth's parent to determine if any medical follow-up was needed Suicide Prevention The agency has a written plan in place that details the programs suicide prevention and response procedures.the plan complies with the procedures outlined in the Florida Networks Policy and Procedure Manual for CINS/FINS. A review of four files was conducted, including two open residential files, one closed residential file, and one closed non-residential file. All four files were found to be in compliance with the standards according to reviewed indicators. All youth were screened, using the CINS/FINS Intake Assessment form, for suicide risk at admission. If the youth answered "yes" to any of the six questions then an EIDS assessment was completed. All CINS/FINS Intake Assessment forms were reviewed and signed by a supervisor. One of the four files required the youth be placed on suicide precautions until a full suicide risk could be completed. The full suicide assessment was completed by a licensed counselor and the youth remianed on close supervision for the duration of her stay. Though the youth was found to be low risk and have no current suicidal ideation, the staff recognized the need to be certain due to the youth's self-report of feeling continuously sad and hopeless. Their efforts to insure the safety of the youth and others went above and beyond the standard and is commendable. There was comprehensive documentation throughout the file of follow-up and recommendations. Observations of the youth were maintained every fifteen minutes throughout the entire duration of the youth's stay. page 16 / 19

17 All files reviewed contained use of the phrase "Youth denied all the above" found on the CINSFINS Intake Assessment Form for Risk Screening sections on page one rather than to leave the lines blank. It appears inclusion of this phrase confirmed the youth's self-reported answers of "no" to all previous questions and acted as a redundant method to insure youth's self-reported emotional, mental, and physical stability at the time of intake. All training files reivewed documented all staff were current on suicide prevention training Medications The review of this indicator was accomplished by means of visual inspection, review of random youth medication files, interviewing the Residential Program Manager, and review of one open residential file. There was one youth in shelter at the time of the review taking medication. The youth had refused to take the medications several times. Each time, an entry was made in the shift log book in the Intake Office with pink highlighting and in his client file in the Client Contact Notes.. All youth with medication have a separate binder inside the double-locked controlled medication cabinet located in the Intake Office. When medication is administered, important/critical information pertaining to the medication is readily available to the staff completing the task. If a need arises to contact emergency services due to a medical issue while administering medication, the staff has all important information at his/her fingertips to inform emergency services rather than having to hunt for it during the crisis. The youth's name, picture, allergies, date of birth, and alerts are found on the front cover of the binder. Each binder contains common side effects and/or precautions for medications, the policy, and the medication administration log sheets, one for each medication. The staff administering the medication signs the sheet as well as the youth receiving it. All medications are stored appropriately inside their original containers bearing up-to-date prescription labels. Medication requiring refrigeration is stored in a lock box inside a locked refrigerator in the locked File Room. Medication is administered by trained staff using appropriate equipment and given to each youth individually at his/her prescribed times. An entry is made in the shift log book and highlighted in pink per the program policies. All storage cabinets and storage areas were found in clean and serviceable condition. All medication was arranged neatly and organized to ease the mandatory daily/weekly/motnhly inventory processes. A sharps container is located inside a locked cabinet to the right of the east door of the Intake Office. The sharps container was found to contain used disposable razors. The Acting Program Manager reported the container is rarely emptied due to the facility lacking the authorization to administer injections. Over the counter (OTC) medications are stored in a locked cabinet in the Intake Office separate from the narcotic and controlled medications. OTC medication is inventoried weekly as found on an inventory sheet taped to the inside of the cabinet door. A supply of OTC medication is kept in the File Room in a locked cabinet and inventoried monthly, or as needed, as evidenced by an inventory sheet taped to the inside of the cabinet door Medical/Mental Health Alert Process page 17 / 19

18 The Youth Shelter has a policy and procedure in effect for this indicator. They have a color code system in place that addresses medical, mental health, allergies, substance use, and trauma. The color code system is as follows: Red Dot = Medical issues Yellow Dot = Mental Health issues Green Dot = Allergies Blue Dot = Substance Abuse issues Orange Dot = some type of Trauma The system also includes precautions concerning prescribed medications. When a youth is placed on medication a list of side effects are placed in the medical files beside the medical chart. All staff are provided sufficient training, information and instructions that allow them to recognize and respond to the need for emergency care and treatment. The training is also noted in their training log. Three youth files were reviewed and all three youth were screened for medical issues. They were appropriately placed on the color coded alert system and their files were color coded with a dot according to their condition. A chart in the staff office also had the youth's name along with the color coded alert Episodic/Emergency Care The review was conducted using visual inspection/verification, review of two open residential files, one closed residential file, review of the Episodic/Emergency Care log, and review of staff training records. All staff members are current with annual training for First Aid and CPR. The Shelter Program Manager is a certified instructor for these courses. The shelter's policy stipulates staff certification is to remain current for these courses as a condition of employment. All three files reviewed were found to be in compliance. The Episodic/Emergency Care log was found to be up-to-date and in compliance. A sealed first aid kit is located in the intake office in a locked cabinet next to the east door. Sealed first aid kits are located in each shelter vehicle. Two spare sealed first aid kits were found in the locked OTC medication storage cabinet in the locked file room. Knives-For-Life are located in the intake office in the same locked cabinet as the First Aid kit and in the locked file cabinet adjacent to the population board. Both knives were visually inspected by a staff member with the reviewer observing and were found to be in good working order. Emergency services telephone numbers were posted in conspicuous locations, including poison control inside each medication cabinet and on a large poster-sized sign with a green border in the intake office. page 18 / 19

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